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STATE @f #[gAA51fA-@EPAATiAE#T Of HEALTH
<br />~~~ 7 = : , ~ ~ ~ BUAEAt! Qf VITAI STATkSTiCS
<br />CER7lFlCATE OF 4~EA~"t! ,, ~ •.
<br />~~--^--______.__...-. __._.-_-_ ___..__ ,_;_ 7E 4i~DEATi1 (AI¢ Dad, Ir.J__._-___-~_.._
<br />DEC"eDENT -HAMF FIRST MiDDtE 4A~T TSf%~~~ ~~ FDA '
<br />,. ~{rlRl~' Nt.1I ,1£IfR T1,Fema.F,t. ~, lkcr 12 i97~ __
<br />' RAC E-(e g (~ hne, R!¢cE, Amara a C+RiCEN)DESCENi (e-g., t 1' n, Me.isaw, AGE bn pinYdar I~V NDER f TEAR i_~ UNDfR 7 DAY DATE OF BIRTH (Ma ,Day. Yr)
<br />en,i,~~cdy] o Iverm n, 'rte ~: tYn.! MGS - pAY3 HOUR. MINS ....,
<br />)~^~ <. z'! Is Ge/crnari ~,aa lQ2 1eb. _ ~~<._ ~ Ir. Ju2~ 20,-1f76
<br />1 -. CITY RMQ SiifE OF 61RTH t# aaf in U 5 A., 'CIfiZ{N 6f WHAi COVHYRY ,MARRIED, NEbER MARRifp NAME OF SPOUSE lrl w~0e. g:re m¢.d.n nnma)
<br />f R~€t..°..ir:a~~ .J°~i~l~~D~r~~ ~ ~, fl a wlDq~Z ~1?d7e~DtsP.<,vy)~~
<br />vur7i3ri~y LF c 5. fl. ip. 91. - - _ __
<br />- - 56CEpA~[SEyCURI7Y NUMBER L65UAL OCCUPAT70N(G r. kind ¢Fw¢r4 down dpnng nrort KIND OF BUStNE350R INDUTIRY COUNTY Of DEATH
<br />~ 7~i°~~°(}3'~Or 7 FworErrg GF~ F r'Sa q~ ~vC -
<br />12. Ii3a fl(7f.!!S(GL4C e - 136. Damee.z:cc ~a ttWfyC
<br />CfiY, YOwN OR LO/CAT7~6+Np OF DFATN INSIDE CITY LIMITS HOSPITAL OR OTHERIN>TITUitON-Nome tf(nar».1»r, If NO3R tlR INbi-Endear. DDa.
<br />S - tab. C.2~[tutd ISZand (SPYCtfyY~3 NcJ ! glre FoeN d n mbv) i C,.POn. E~m. Fn. ,nw,»., f Sa«~.Sr, -_ -
<br />- ac. 74d. ~a1C~2JJ-Cde A{atzoh ,1•a. InpEZ,then~
<br />- RESIDENCE-57ATf COUNtt ~C17Y, iOWN OR iCC.ATEON 'STREE7AND NUMdfR INSIDE CITY IIMtfs - '
<br />Neoxa.3txa y_~~ 5~~--_-J I.~.@arrd isd 6l0 N, t}zJUt se•<;~Qr~.arNa,
<br />i5o. SSb. Ha.~f 7 i31(.ai'tlL ~-
<br />i kTHER-NAME FIRST MIDOtE LAST THf,R-MAl0.N NAME fIR3T MI DLE -- tAjj'"--""'~-
<br />E a_~_,___ Ca.~~e~c -_-- tleie~c I7T [Utezrzousz _ --- Unhrcocuz
<br />E WAS DECEASED FVFR tN U S ARMED fORCESi ~ INFORMANT-HAMF-REtAffONS!!lP_MArUNG ADDRESS ITiREfT os t i D ND.. Citt OF iOvrN, SERIF, 21F1
<br />~ (18>,a~~,E,iEtr,=,.s:....a.<ed.al.,af..,.,.., {leruy ?ledvc 5o:r ~Jorri.ptzcuz, heb~Ta~ha dBk32
<br />19
<br />BUR1Al, CremolFon. Aemool ATE ~ CEMETERY OR CREMATORY-NAME -
<br />~ ` 1 ~ ~ ~ q L! OCATtON CITY OR TOWN STATE
<br />2 _ F 2~ CedcvE V~.ezv Cerrre~tevcy ~ Uarziphan, NeGna~ska
<br />2Do. tare ..._,___L?Da_
<br />ER- 1GM RE i EN NO~ !FUNERAL NOME -.NAME AND ADORE35 _ r31FEfi OE K F p NO. CI7Y OR tOWN. TiatF. firy - - -
<br />z3 v8~i2~6e~-IIut~¢~c-Geddes 1123 f~F 2nd, Grand I3~arxd, NE, b880_1
<br />---ia ~ - ay Eoaelad9e, demY en,»d a, rM nms, ¢g~ and ,fa» end dra m xM ! fa rM bm:a of a+aminanaa andia, : ~ r[:paYaw, " ~r oPeaial. dao+3 aeer.nad aY r
<br />~ ra af•1 uvssd. ~1 ~~ ) r~~ ~ me unw, daN a,d tEare ud dw ~ . wvaef.i Mo»d,
<br />u S:Rwp(u» aad T.Ne) ~~ , „I
<br />is f Sc \F\ ~2l'!E\C, ~M ~IaYQ +2aa tsxy,wrr»awa r,n.i~
<br />pA E iGNED (Ma., Day, Yr.J THOUR OF DfATN '.C DA N p lMe. ¢y, Yr.} E U ATH
<br />a°tl 236. t~C." SZ-~~ _j3u Y r. l~L: ~ M ~k`2 °~Iab -.
<br />` _ 24. M
<br />~~ rDATf OF DEATH fAta., Da,. Yr} bpp {PFONOUNCfO DEAD PRONOUNCED DEAD(Hauri
<br />^,~j23d 1Z i~' ~ i I i2Ed ~2a M
<br />NAME AND ADDRESS OF CERNNER (PHT$lCiAN. CGRONER'S PHYSICIAN OR COUNTY ATTORNEYy ((ype ¢. Pr:nl)
<br />.s J. J. Canrze.2ta. t.l.-. _724 N. CcuStEJt, Grand Ib2and, N_E. 68fsU1
<br />~RFG!$TRAR ~~~~j/)~ j/~/j/,/ ~ DATF R/f(~~+~1P!/U B/Y REG/i,S/i R/,U/i fMO.,/Do/p, fr.)7
<br />2ao./SipaaN»i® ~ 74V~~'L L" l •~ __ ~ 266 f4~ A~ Z ~ E ~ L
<br />~ 2J. iMMfDI~' JY (ENTER ONLY ONE CAUSE PfR UNE FOR (a), 76}, ANC (<il '~^ -
<br />' PART ~ In ber n eM dead, -
<br />t
<br /># DUE 70. OR A CONSEOUENCE OF: a '----- I w...e, -.w aea a.aro _ _ _
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<br />DUE TO. OR AS A CONSEQUENCE CF: ~ -~..- --'~' ~__ - -` .n*.sl bs.«eew rfs! aae dw4
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<br />i~Ti~r R SrGH,HCANT CONOIirON3 -C<ed;+;oa. rmre•¢.x~es m draw b.,r ea .^.-M 7' ~ -- -- u ^'- x -- N sf tflEiREp f0 MECKI~~u-
<br />- E7 - ~ E -NCI I.-E SlI~G 5 ;-:~~~fr i rEX fE.W£OROI}fR
<br />ACGOFIFt, SYEtzpL'. EJOwC70F, UNDEi.-DATG Of eNIURi fMa. Dor, i.; i~EU ~,WUKY Ya Ci SCRdf nO U G~CUFtip/
<br />' DR fENpNC rNYESttUfION 73pe..kt {
<br />INFUEY AT w~K iltACF DT N. _ » E.ma, t..m- msax, lash.,- iGLATrON ~ S:lf Ei OR i r p N CETY OR iOW N TTAEE
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<br />$+1~~N THIS ~b`~PY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />_~~AT~` T~E° g~'tIENT OF HEALTH, IT CERTIFIES THE AB04E TO BE
<br /><~' TR~~3 ~38'X°'JF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />+~k~`AF.df~!~?E' OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />TS~~fiHE`~LEGAL DEPOSITORY FAFO}_R .FITAL RECORDS.
<br />CJ F
<br />~~ ~~~
<br />DIRECTOR OF VitAL STATISTICS AN3? ASBI$TA_,STATE REGISTRAR
<br />LINCOLN, N]Ez~A~~A I s s ueit ecez@ber 22 , 1 ~ 78
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